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‘The Sound of Silence’ in Audiology

2023; Lippincott Williams & Wilkins; Volume: 76; Issue: 07 Linguagem: Inglês

10.1097/01.hj.0000946108.49417.d0

2333-6218

JOHN G. CLARK,

Music Therapy and Health

“… you do not know. Silence like a cancer grows.” – Paul Simon, Capital Records, 1964 The immutable lyrics embodied within Paul Simon’s 1964 hit, “The Sound of Silence,” can serve as a poignant reminder to clinicians of the need to give voice to the often-unvoiced words in a clinical exchange. As Art Garfunkel, the other half of the successful singing duo, once noted, “The Sound of Silence” is about “…the inability of people to communicate with each other, not particularly intentionally but especially emotionally…” 1www.shutterstock.com. Viewpoint, silence, patients.In any clinical encounter, there are two types of silence of which clinicians should be aware. The first is a therapeutic silence that we should capitalize on. The second is an avoidant silence, which Simon and Garfunkel’s ballad illuminates. We should strive to minimize this second—often harmful—-silence to lessen the cancerous effects it can have on the working relationships we strive to attain with each patient. THERAPEUTIC SILENCE The first silence serves a therapeutic role, yet as beneficial as it can be to the forward movement of patients and families in a rehabilitative context, it is often glossed over or filled in. While few of us have a true sedatophobia–fear of silence–most all of us are uncomfortable with silence to some degree. It is possible that this discomfort has become more prevalent over the past generation as technology has allowed us to sedate our thoughts through a constant barrage of music, podcasts, cell phones, audiobooks, television, push notifications, and the like. 2 Discomfort with silence causes our minds to race during conversational lulls in an attempt to think of something to say to quickly fill the void. It is important that we not allow this somewhat normal phenomenon in social contexts to bleed over into clinical exchanges. When we pause before responding to an emotionally charged statement, the patient is afforded a moment of reflection. Similarly, when the clinician is speaking, if the patient breaks eye contact, appearing to process what is being said, a brief pause is often helpful. This “attentive waiting” can provide temporal space for reflection and an opportunity for patients to assume greater responsibility for their own progress. When we fill a silent pause too quickly with a comment or question in an effort to maintain discussion, we can disrupt the patient’s thoughts or sidetrack an issue that may not have been fully explored. 3 Sometimes what the patient says following a brief silence shifts the focus of the dialogue in a direction of greater importance for the patient at that moment. Regardless, if there is a shift in direction, when dialogue continues, we are ensured we have the patient’s greater attention. 4 AVOIDANT SILENCE As beneficial as a brief, well-timed, silence can be for the patient and for the overall clinical exchange, the other type of silence that often appears in clinical dialogues, the avoidant silence, can create a distance between the audiologist and patient, which fails to foster rapport. Instead, the avoidant silence can leave patients feeling unfulfilled through a perceived lack of an understanding of, or appreciation for, the circumstance they find themselves within. An avoidant silence may exhibit as a true silence as may occur in the clinic when a patient makes an emotionally charged statement and the clinician, being at a loss for words, does not respond. More often, an avoidant silence is not a literal silence within a dialogue, but may be evidenced when a clinician’s subsequent remark fails to acknowledge the emotions within the patient’s comment. Either form of avoidant silence leaves unaddressed the emotional context that often envelops many clinical scenarios. Paul Simon and Art Garfunkel harmonize beautifully as they lament a difficult truism of many situations: “People talking without speaking; People hearing without listening; And no one dared Disturb the sound of silence” 5 Too frequently in a clinical exchange, as Simon says, words fall like silent raindrops and echo “in the wells of silence.” 5 Only when we remain attuned to the full dynamics of our clinical exchanges with patients, can we begin to listen with our hearts revealing opportunities to address the unspoken. There are times in which we seem to talk without speaking as when we continue, for example, with information on the prevalence of otitis media in children and the rates of reoccurrence after a mother complains that her child’s otitis media keeps coming back with subsequent delays in progress with speech therapy. While our talking may be providing important information, we are not speaking to the emotion of frustration underlying the mother’s words which should be acknowledged before proceeding. We sometimes seem to hear without listening as when a younger adult patient states that he thought hearing aids were only for old people and we point out the number of pediatric patients in our practice. We are hearing the words, but we are not listening to the disappointment and disbelief that this diagnosis may have engendered. When a father questions the results following testing of his child’s hearing, he is not necessarily passing judgement on our clinical expertise. More likely he is simply exercising his right to retreat into a normal state of denial as he temporarily grapples with the emotions he prefers not to confront. Rather than defending our test approach, or explaining the science behind the technology, we must speak to the emotions at the root of his questions. When an elderly patient wonders aloud why she has lived so long, the audiologist might respond with a relatively inappropriate reassurance that things will seem brighter once the hearing loss is successfully addressed. The avoidant silence within such reassurance is nearly palpable to one attuned to the sadness beneath her words that are left unaddressed with comments that can only serve to make the clinician feel more comfortable following an emotionally charged remark. Often, we do not dare disturb the sound of silence that arises as we avoid addressing what may seem uncomfortable. This avoidant silence has been referred to as the elephant in the room and it needs to be addressed openly. When patients are silent when we deliver potentially emotionally charged diagnostic results or treatment options, we should provide a brief pause, and if the patient does not say anything, we should ask directly how what we have said is sitting with them. We need to dare to address avoidant silence. Talking about the elephant in the room demonstrates our attunement with the moment, can strengthen clinical bonds, heighten trust, and improve patient adherence to recommendations. 6 The resultant enhanced professional--patient relationship is one of the foundational factors behind patient satisfaction for services rendered. 7,8 COMPASSIONATE OBSERVANCE An observance, couched in compassion, of the clinical situation we find ourselves within can lead us toward the provision of needed moments of therapeutic silence and guide us past moments of avoidant silence. Let us look back at our earlier scenarios. For the mother whose child’s otitis keeps reoccurring, we need to ensure that we have her full attention as we provide further information. We also need to foster her sense that her concerns and frustrations are recognized and appreciated. We might address the emotion underlying her comment by simply saying, “It must be very frustrating and frightening for you when the ear infections keep coming back.” This statement should then be followed by a brief therapeutic silence. Similarly, the young adult patient who laments that he thought hearing aids were for old people does not need to be reminded that many children also have hearing loss, a fact he surely knows. To foster this patient’s sense of being understood in the moment, we must first address the underlying emotion. An appropriate response might be, “I can understand that what I have just said is not what you were hoping to hear,” again followed by a brief therapeutic silence. The father who may not be fully aware of looming emotions when he questions our test results is in need of reflection on what the diagnosis may mean for his child, himself, and his family. A statement such as, “I would think it could be quite frightening to consider that these results may be correct,” demonstrates our acceptance of the father and the situation in which he finds himself. As before, this statement followed by a brief therapeutic silence and an openness for a response can be quite powerful. Finally, the elderly patient who questions her continued time on this earth needs to know that she has been heard. An appropriate response might be, “It must be difficult to have so many things change in the course of a lifetime, and not always in the ways we had hoped.” And again, a brief therapeutic silence should follow. When we listen from the heart through a compassionate observance of the impact of our words or our treatment, and a vigilance for the presence of emotionally laden responses that our patients may give, we find that we can provide more appropriate responses. CAN WE DO THIS? The second component of person-centered care in audiologic practice requires a therapeutic listening to our patients through “a demonstrated attempt toward empathic understanding of the patient/family perspective of hearing loss impact…” 4 The personal adjustment counseling that we provide our patients, including bringing accompanying emotions to the fore, is not provided as a set-aside service but should be infused within every aspect of our care. Audiologists are not mental health professionals. We do not, and should not, provide psychotherapy. As the psychology/psychiatry duo, Kennedy and Charles note, those in “helping professions,” which include audiologists, may guide patients to confront a wide range of psychological, social, and emotional concerns as these might relate to the helping professional’s own specialty area. 9 Personal adjustment counseling takes many forms and is squarely within our professional domain. Helping patients to give voice to the emotional undercurrents accompanying hearing loss is an important aspect of our care. We can most certainly do this. The emotions that patients experience are a part of the normal grieving process. Acknowledging these emotions and helping patients recognize the universality of their feelings is a necessary portion of the rehabilitation journey and takes only brief moments of clinical time. It is paramount in this process that audiologists recommend support groups for parents. While adults often arrive at our doors in a more developed stage of acceptance of hearing loss, some do not. It can indeed be emotionally upsetting for our adult patients when we tell them that their hearing loss is not caused by ear wax, that there is no pharmaceutical or surgical intervention, that the hearing loss is permanent, that it will progress with time, that hearing aids are indeed needed, and that our treatment cannot fully restore all of their lost communication abilities. Just like the parents of our pediatric patients, many of our adult patients grapple with emotions following diagnostic pronouncements and treatment recommendations and can benefit from peer support as may be found through consumer groups like the Hearing Loss Association of America. Our role further includes a vigilance for persisting or chronic emotions that can negatively impact adjustment to hearing loss, acceptance of available technologies, and positive interactions with others. When we observe such blocks to successful rehabilitation, it is our ethical responsibility to be prepared to make a needed referral to a mental health professional. In keeping with the dictates of the American Academy of Audiology Code of Ethics 10, we must use every resource available to provide the best service possible for our patients. The positive impact of our words that may acknowledge unspoken or veiled emotional undercurrents are often immeasurable but may add only seconds to the clinical encounter. To paraphrase Sir William Osler: the good audiologist treats the hearing loss; the great audiologist treats the patient and family living with the hearing loss.